Topical presbyopic correction: a postoperative problem solver

The first of a raft of new presbyopia-correcting eyedrops recently hit the market, with several others slated for FDA approval in the next few years.

Presbyopia has vexed patients and eye physicians since the beginning of time. However, the first of a raft of new presbyopia-correcting eyedrops recently hit the market, with several others slated for FDA approval in the next few years.

Presbyopia-correcting drops represent a whole new product category—one with a lot of upsides for clinicians who want to help their patients see well at all distances.

First introduced was Vuity (Allergan/Abbvie). Additional offerings from Visus Therapeutics, Orasis Pharmaceuticals, Ocuphire Pharma, Lenz Therapeutics, and Eyenovia are all still under investigation (See Table 1).

Not only do these miotic, pupil-modulating drops have the potential to bring many young presbyopes into our practices, but they can also help us address postoperative problems that have previously been tricky to solve.

For example, we know that the vast majority of patients undergoing cataract surgery do not take advantage of presbyopia-correcting IOLs, due to cost or lack of eligibility. To me, helping these patients with standard monofocal IOLs achieve seamless vision is one of the greatest opportunities we have. Patients who see well at distance already may not need glasses much at all, but presbyopia-correcting drops could help pseudophakic patients regardless of their refractive posture. A distance-corrected individual could use the drops to avoid the fall risks associated with bifocals and progressive spectacles, for example.

Additionally, we all have those disappointed patients in our practices who did pay out of pocket for premium IOLs and were underwhelmed by the results. Maybe they had an early bifocal lens that did not provide intermediate vision, or extended-depth-of-focus (EDOF) IOLs that provide quality “walking around” vision, but they could benefit from better reading vision. By providing a smaller pupil, miotic drops could even eliminate some of the dysphotopsia symptoms that plague a small percentage of patients implanted with diffractive IOLs.

I believe that presbyopia-correcting drops are going to nicely fill the gap for all of these types of dissatisfied pseudophakic patients.

Making the most of monovision

For patients who have surgical monovision, whether from prior LASIK or cataract surgery, we could consider using presbyopia-correcting drops in just the distance (dominant) eye or in both eyes, to provide better intermediate and near vision.

An exciting feature of miotics, as topical presbyopic correction, is that they likely won’t compromise distance vision, which makes them an option for those who just have one eye corrected for distance. So far, data suggests that new formulations of drugs like pilocarpine and carbachol are able to reduce the pupil size by about half, with a near vision gain of 2-4 lines with less than one line of distance vision loss. I’m pretty confident that most of our patients are going to be able to function really well with these drops at distance, even in mesopic lighting conditions.

Some patients cannot adapt to the disparity between the two eyes with monovision. Others struggle with glare and halo at night because of the disparity. Before I would recommend giving up on monovision and surgically correcting it on the cornea (which has its own risks and disadvantages), I would love to be able to try pupil-modulating drops to see if they relieve the problems the patient is experiencing.

Historically, one of our treatment options for patients struggling with glare and halo was to use topical brimonidine, a sympatholytic alpha-2 agonist, to stabilize the pupil and reduce glare, so it is entirely possible that presbyopia-correcting drops with similar effects could help reduce night vision symptoms. Because these drops act on the iris, their presbyopic effect is much closer to the eye’s nodal point than a corneal correction, which may also result in a “truer” version of monovision for our patients who would otherwise seek an enhancement.

Opening up the presbyopia conversation

Discussion around presbyopia has always been one of the most difficult conversations to have with patients. Losing the ability to read menus is one of the first harbingers of old age—and it is not a welcome one! Because that conversation can be so fraught and, frankly, confusing for patients to understand, many of us avoid “the presbyopia talk” until absolutely necessary. With the proliferation of more options for presbyopia correction at every stage, including noninvasive pupil-modulating drops, I would love to see our profession proactively discuss presbyopia much earlier in the game and truly embrace the notion of seamless vision for life.

Patients are going to be excited when they hear about these drops.

Patients want choices and options—and the reality is that 50% of presbyopic patients never even get an eye exam. The availability of a prescription eyedrop for near vision will elevate the importance of scheduling an eye appointment. And when the patient is in your office, they will realize there are other options that are also better than drug store “cheaters.” I firmly believe that attracting more patients with presbyopia into the office will ultimately pay off in both retail sales, exam billing and happier patients.

Customized care

I love the notion of being able to provide a therapy that allows patients to pick and choose when they want to use it. Pupil modulating drops do not take weeks or months to reach peak efficacy; rather, they work in minutes and without consequences to skipping doses. Furthermore, patients will continue to get the same results weeks to months after starting the medications.

In the GEMINI clinical trials of the first available presbyopia-correcting drop, Vuity, the drop met its endpoint of improved near vision at 3 hours (26%-31% of patients met this endpoint, statistically significantly more than in the control group). Although 16% to 18% still had good near vision at 6 hours, the difference was not statistically significant. There were no serious adverse events. Headache and eye redness, occurring in >5% of patients, were the most common non-serious events.

Future presbyopia-correcting drops may have an even longer duration of effect. An early readout of Phase 2 data from the VIVID clinical trials for Brimochol (Visus Therapeutics), for example, showed that 82%, 52% and 35% of patients maintained a 3-line gain in near vision at 3, 7, and 9 hours, respectively.

We will reach a point at which patients can instill drops in the morning and have good vision for their entire workday. There will also be ample opportunity to customize treatment to patients’ needs. Some may want to use the drops only during the week at work, whereas others do not mind glasses when sitting at a desk but would like to be unencumbered for exercise or going out on the weekends. This solution does not have to be "one size fits all."

When we consider putting patients on any new medication, we need to find the best population of patients with the attributes to be successful.

Furthermore, we always must weigh the risks and benefits. Here, I expect the benefits will be high and the risks extremely low. There will be very little downside to offering presbyopia-correcting drops to patients who want better near vision without glasses or contacts.

Marc R. Bloomenstein, OD, FAAO

E: mbloomenstein@gmail.com

Bloomenstein is director of optometric services at Schwartz Laser Eye Center in Scottsdale, Arizona. He is co-founder of the Optometric Council on Refractive Technology (OCRT).